Excellent Community Home Healthcare LLC

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Based on record review, interview and policy review, the agency failed to ensure patients received home health care services as written in the plan of care. See G572.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on record review, interview and policy review, the agency failed to ensure patients received the home health services as written in the plan of care. This affected three (Patients #1, #2 and #3) of three patients reviewed. The agency census was 25. Findings include: 3. Review of Patient #1’s medical record revealed an admission date of 08/30/24, with diagnoses to include diabetes mellitus type I, cerebrovascular accident (CVA), major depressive disorder, seizures, chronic kidney disease (CKD), left side hemiplegia and hypertension. Review of the plan of care/physician’s orders dated 08/30/24 to 10/28/24 revealed orders for skilled nursing twice daily for 9 weeks, and home health aide services of 54 hours per week for nine weeks. The orders stated the physician was to be notified of fasting blood sugars (FBS) greater than 300 milligrams per deciliter (mg/dl) and a non-fasting blood sugar (NFBS) greater than 400 mg/dl or any blood sugar below 60 mg/dl. Patient #3 was to receive Lantus (long-acting insulin) 8 Units (U) every morning subcutaneously and a sliding scale of Novolog (short acting insulin) subcutaneous, 6 U if he eats 100 percent of his meal, 3U if he eats 50 percent of his meal, and none if the patient eats less than 50 percent. This is to be administered right after meals three times a day. Review of the skilled nursing notes from 10/08/24 through 10/14/24 revealed Staff C (nurse) noted the patient refused the sliding scale insulin on the following visits: 10/08/24 PM, 10/09/24 PM, 10/10/24 PM, 10/11/24 AM, 10/12/24 AM, 10/12/24 PM, and 10/14/24 AM. The scheduled AM Lantus was not documented as administered as ordered by the nurse on 10/09/24 AM, 10/10/24 AM, 10/11/24 AM, 10/14/24 AM or 10/15/24 AM. Review of the skilled nursing note dated 10/13/24 at 8:45 PM revealed Staff C assessed the patients blood sugar at greater than 500mg/dl and administered insulin, however the note does not reveal how much or what insulin was provided. There was no physician notification of the elevated blood sugar. There was no re-check of the blood sugar noted. Review of the skilled nursing note dated 10/15/24 revealed the skilled nurse did not assess the patients blood sugar or vital signs. There was no AM or PM insulin noted as administered to include the scheduled morning Lantus or sliding scale NovoLog. There was no physician notification documented in the medical record of refusal or missed medications. In addition Staff C noted wound care to a left heel and fifth toe wound was completed during the evening visits on 10/08/24, 10/10/24 PM and 10/14/24. There were no wound care orders noted on the physician ordered plan of care. These findings were verified during an interview with the Director of Nursing on 12/10/24 at 5:00 PM. Review of the agency policy titled “Skilled Professional Services” revealed patients receiving skilled professional services will receive appropriate assessments, reassessments, care planning, established outcomes and care per physician orders. Skilled professionals must assume responsibility for providing services ordered in the plan of care, preparing clinical notes and communication with all physicians in the plan of care and other health car practitioners related to the plan of care. 1. Review of the medical record for Patient #2 revealed a plan of care dated 09/26/24 to 11/24/24 with orders for skilled nursing weekly and home health aide services 25 hours per week. The medical record contained a plan of care dated 11/25/24 to 01/23/25 with orders for skilled nursing weekly and home health aide services three hours per day, five days per week. Review of the medical record from 11/10/24 through 11/30/24 revealed home health aide services provided five hours per day, five days per week, for a total of 25 hours per week. On 12/05/24 at 2:30 PM, the electronic medical record (EMR) showed nursing visits from 09/26/24 through 11/19/24 were scheduled daily but listed as not yet started. Time sheets containing the date, time of visit, staff signature, and patient signature showed the daily nursing visits were completed for this date range. The EMR contained completed skilled nursing visits daily from 11/20/24 through 12/04/24. The medical record lacked documentation of any additional skilled nursing or home health aide orders. During an interview on 12/05/24 at 2:30 PM, Staff B verified the above findings. 2. Review of the medical record for Patient #3 revealed a plan of care dated 09/11/24 to 11/09/24 with orders for skilled nursing twice a week and home health aide services 12 hours per week. The medical record contained a plan of care dated 11/10/24 to 01/08/25 with orders for skilled nursing twice a week and home health aide services 19 hours per week. On 12/05/24 at 2:30 PM, the EMR showed nursing visits dated 11/15/24, 11/19/24, 11/20/24, 11/24/24, 11/29/24 were scheduled but listed as not yet started. Time sheets containing the date, time of visit, staff signature, and patient signature showed the nursing visits for these dates were completed which would have been twice a week. Review of the medical record from 11/10/24 through 11/30/24 revealed 18 hours of home health aide services per week. The medical record lacked documentation of additional home health aide orders or that the physician was notified the care was not provided as ordered. During an interview on 12/05/24 at 2:30 PM, Staff B verified the above findings. During an interview on 12/05/24 at 4:15 PM, Staff B stated the book that she documented the vital signs during her visits was at home so it could not be provided. Staff B verified the skilled nursing notes for Patients #2 and #3 that were listed as not yet started were now completed. Staff B stated she knew the range of vital signs for these two patients.”

“Be free from abuse CFR(s): 484.50(c)(2) Be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property; This Element is not met as evidenced by: Based on record review, interview and policy review, the agency failed to ensure patients were free from neglect. This affected one (Patient #1) of three patients reviewed. The census was 25. Findings include: Review of Patient #1’s medical record revealed an admission date of 08/30/24, with diagnoses to include diabetes mellitus type I, cerebrovascular accident (CVA), major depressive disorder, seizures, chronic kidney disease (CKD), left side hemiplegia and hypertension. Review of the Resumption of Care (ROC) Outcome and Assessment Information Set (OASIS) dated 10/07/24 revealed the patient was chair-fast, wheelchair bound and unable to transfer himself or ambulate with the wheelchair. The patient required assistance for all activities of daily living to include, dressing and toilet hygiene. Review of the plan of care/physician’s orders dated 08/30/24 to 10/28/24 revealed orders for skilled nursing twice daily for 9 weeks, and home health aide services of 54 hours per week for nine weeks. The orders stated the physician was to be notified of fasting blood sugars (FBS) greater than 300 milligrams per deciliter (mg/dl) and a non-fasting blood sugar (NFBS) greater than 400 mg/dl or any blood sugar below 60 mg/dl. Patient #1 was to receive Lantus (long-acting insulin) 8 Units (U) every morning subcutaneously and a sliding scale of Novolog (short acting insulin) subcutaneous, 6 U if he eats 100 percent of his meal, 3U if he eats 50 percent of his meal, and none if the patient eats less than 50 percent. This is to be administered right after meals three times a day. Review of the skilled nursing notes from 10/08/24 through 10/14/24 revealed Staff C (nurse) noted the patient refused the sliding scale insulin on the following visits: 10/08/24 PM, 10/09/24 PM, 10/10/24 PM, 10/11/24 AM, 10/12/24 AM, 10/12/24 PM, and 10/14/24 AM. The scheduled AM Lantus was not documented as administered as ordered by the nurse on 10/09/24 AM, 10/10/24 AM, 10/11/24 AM, 10/14/24 AM or 10/15/24 AM. Review of Patient #1’s skilled nursing note revealed on 10/08/24 at 9:20 PM-10:00 PM the nurse noted he found the patient sitting on the couch in urine and feces. The patient reported emergency medical services (EMS) had just left the home after getting him up off the floor. The patient reported he was unable to reach his phone or emergency alert button and he was the only one in the home. Review of the skilled nursing note dated 10/13/24 at 8:45 PM revealed Staff C assessed the patients blood sugar at greater than 500 mg/dl and administered insulin, however the note does not reveal how much or what insulin was provided. There was no physician notification of the elevated blood sugar. There was no re-check of the blood sugar noted. Review of the skilled nursing note dated 10/15/24 revealed the skilled nurse did not assess the patients’ blood sugar or vital signs and noted his medication was left within reach and instructed aide to remind the patient to take it. The skilled nurse noted the patient was asleep and he did not awaken the patient due to previous requests not to, for the 10/15/24 morning and evening visits. There was no AM or PM insulin noted as administered to include the scheduled morning Lantus or sliding scale NovoLog. There was no physician notification documented in the medical record of refusal or missed medications. On 10/16/24 at 8:36 AM the home health aide (Staff A) arrived to find the patient on the floor unresponsive and soaked in urine and feces. Emergency Medical Services (EMS) was called with a complaint of an unresponsive patient and transported the patient to the hospital. Review of the Squad Run Report revealed on 10/16/24 EMS arrived at 8:49 PM, the patient was unresponsive and incontinent of urine. Vitals signs were noted as 191/83-33 gurgling respirations-94 percent on bag valve mask 10 liters (L)-25 end-tidal carbon dioxide and a 586 blood glucose level. The patient had a clenched jaw and was nasally intubated. EMS noted the primary impression as diabetic hyperglycemia. The patient was taken to the hospital emergency room. The patient was admitted for diabetic ketoacidosis. The patient was treated in the emergency department, pulseless electrical activity was noted and advanced cardiac life support efforts were initiated there. The patient had a return of spontaneous circulation but suffered anoxic brain injury. Magnetic Resonance Imaging (MRI) was obtained showing global hypoxic ischemic injury. An electroencephalogram (EEG) was obtained showing no detectable electrical activity. The patient was absent of cough, gag and corneal reflexes. Terminal extubation was completed on 10/19/24 at 5:30 PM. The patient expired at the hospital on 10/20/24 at 2:15 PM. During an interview on 12/09/24 at 9:08 AM, Patient #1’s family member stated Patient #1 could not move much, he needed help with everything to include eating and dressing. He could not walk or use hardly use his hands for the last 6 months of his life. She stated he lived alone and wore a medical alert necklace. During an interview on 12/09/24 at 10:59 AM, Staff C (Patient #1’s nurse) revealed on the morning of 10/15/24 he visited the patient and found him on the floor by the couch. He stated he looked at him and he was breathing “fine”, and everything was “ok”. He verified he did not do vitals or obtain the patient’s blood sugar. He stated the patient did not want to wake up based off of what the patient had previously told him not to wake him up on dialysis days. Staff C stated later that day for the evening visit the patient was asleep and he did not wake him, check his blood sugar or assess the patient. He said he looked at the patient and saw he was breathing, set the patients medications up and told the home health aide to remind the patient to take them when he woke up. He verified he did not administer insulin on 10/15/24 for either visit. He stated he did not notify the doctor of any refusals or elevated blood sugars, although put it in his notes. Staff C stated the patient refused his insulin frequently. During an interview on 12/09/24 at 10:42 AM, Staff A (Patient #1’s aide) revealed on 10/15/24 he found the patient asleep on the floor. He said he tried to get he patient up off the floor and called the patient’s family member. The family member instructed the aide to get the patient ready for dialysis by 11:00 AM. He said Patient #1’s family member came with breakfast for the patient. The aide said he fed the patient because he a hard time feeding himself and got him ready for dialysis. These findings were verified during an interview with the Director of Nursing (DON) on 12/10/24 at 5:00 PM. The DON stated the patient was noncompliant and always refused his insulin. The DON stated she requested more hours because the patient required more care but it was denied. She stated the case manager was talking with the patient about going to a skilled nursing facility. The DON stated, “I should have discharged the patient.” Review of the agency policy titled “Patient Bill of Rights and Responsibilities” revealed patients have the right to be admitted by the agency only if it has the resources needed to provide the care safely and at the required level of intensity, as determined by a professional assessment. The patients have the right to receive all services in the plan of care. Patients will be discharged from the agency if the discharge is necessary for the patient welfare because the agency and responsible physician can no longer meet the patients needs based on the patient’s acuity. The agency will arrange a safe and appropriate discharge to other care entities when the needs of the patient exceed the agency capabilities. The patient will be discharged from the agency when the patients behavior is uncooperative to the extent that delivery of care to the patient is seriously impaired. The patient will be discharged when the patient refuses to follow the physician prescribed plan of care (physician will be notified).”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on record review, interview and policy review, the agency failed to promptly alert the physician of medication refusals and an elevated blood sugar. This affected one (Patient #1) of three patients reviewed. The census was 25. Findings include: Review of Patient #1’s medical record revealed an admission date of 08/30/24, with diagnoses to include diabetes mellitus type I, cerebrovascular accident (CVA), major depressive disorder, seizures, chronic kidney disease (CKD), left side hemiplegia and hypertension. Review of the plan of care/physician’s orders dated 08/30/24 to 10/28/24 revealed orders for skilled nursing twice daily for 9 weeks, and home health aide services of 54 hours per week for nine weeks. The orders stated the physician was to be notified of fasting blood sugars (FBS) greater than 300 milligrams per deciliter (mg/dl) and a non-fasting blood sugar (NFBS) greater than 400 mg/dl or any blood sugar below 60 mg/dl. Further review of the physician orders revealed the patient was to receive Lantus (long-acting insulin) 8 Units (U) every morning subcutaneously and a sliding scale of Novolog (short acting insulin) subcutaneous, 6 U if he eats 100 percent of his meal, 3U if he eats 50 percent of his meal, and none if the patient eats less than 50 percent. This is to be administered right after meals three times a day. Review of the skilled nursing notes from 10/08/24 through 10/14/24 revealed Staff C (nurse) noted the patient refused the sliding scale insulin on the following visits: 10/08/24 PM, 10/09/24 PM, 10/10/24 PM, 10/11/24 AM, 10/12/24 AM, 10/12/24 PM, and 10/14/24 AM. The scheduled AM Lantus was not documented as administered as ordered by the nurse on 10/09/24 AM, 10/10/24 AM, 10/11/24 AM, 10/14/24 AM or 10/15/24 AM. Review of the skilled nursing note dated 10/13/24 at 8:45 PM revealed Staff C assessed the patient’s blood sugar at greater than 500mg/dl and administered insulin, however the note does not reveal how much or what insulin was provided. There was no physician notification of the elevated blood sugar. There was no re-check of the blood sugar noted. Review of the skilled nursing note dated 10/15/24 revealed the skilled nurse did not assess the patient’s blood sugar or vital signs. There was no AM or PM insulin noted as administered to include the scheduled morning Lantus or sliding scale NovoLog. There was no physician notification documented in the medical record of refusal or missed medications. In addition Staff C noted wound care to a left heel and fifth toe wound was completed during the evening visits on 10/08/24, 10/10/24 PM and 10/14/24. There were no wound care orders noted on the physician ordered plan of care. These findings were verified with the Director of Nursing during an interview on 12/10/24 at 5:00 PM. Review of the agency policy titled “Skilled Professional Services” revealed patients receiving skilled professional services will receive appropriate assessments, reassessments, care planning, established outcomes and care per physician orders. Skilled professionals must assume responsibility for providing services ordered in the plan of care, preparing clinical notes and communication with all physicians in the plan of care and other health care practitioners related to the plan of care. Review of the agency policy titled “Medication Administration” revealed patients will be assessed and re-assessed on an on-going basis for medication effectiveness and/or drug related problems. Staff will use the information from the medication monitoring to assess the medications continued administration and communicate those findings to the patient, physician and any other appropriate staff. Any unresolved significant concerns about medications will be discussed by the nurse with the physician and any other appropriate staff. Review of the agency policy titled “Coordination of Care” revealed the home health agency must assure communication with all physicians involved in the plan of care and coordinate care delivery to meet patient’s needs. Staff must provide the physician with patient information on an ongoing basis regarding current condition, changes in condition, outcomes of care and services, changes in environment and care giver support and results of relevant labs.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure staff prepared clinical notes accurately and timely. This affected three (Patients #1, #2 and #3) of three patients reviewed. The agency census was 25. Findings include: 2. Review of the medical record for Patient #2 revealed plans of care dated 09/26/24 to 11/24/24 and 11/25/24 to 01/23/25 with orders for skilled nursing weekly. On 12/05/24 at 2:30 PM, the electronic medical record (EMR) showed nursing visits from 09/26/24 through 11/19/24 were scheduled daily but listed as not yet started. Time sheets containing the date, time of visit, staff signature, and patient signature showed the daily nursing visits were completed for this date range. The EMR contained completed skilled nursing visits daily from 11/20/24 through 12/04/24. On 12/05/24 at 2:30 PM, Staff B verified the above findings. On 12/05/24 at 4:00 PM, the missing skilled nursing visit notes were completed in the EMR. 3. Review of the medical record for Patient #3 revealed a plan of care dated 11/10/24 to 01/08/25 with orders for skilled nursing twice a week. On 12/05/24 at 2:30 PM, the EMR showed nursing visits dated 11/15/24, 11/19/24, 11/20/24, 11/24/24, 11/29/24 were scheduled but listed as not yet started. Time sheets containing the date, time of visit, staff signature, and patient signature showed the nursing visits for these dates were completed which would have been twice a week. During an interview on 12/05/24 at 2:30 PM, Staff B verified the above findings. On 12/05/24 at 4:00 PM, the missing skilled nursing visit notes were completed in the EMR. During an interview on 12/05/24 at 4:15 PM, Staff B stated the book that she documented the vital signs during her visits was at home so it could not be provided. Staff B verified the skilled nursing notes for Patients #2 and #3 that were listed as not yet started were now completed. Staff B stated she knew the range of vital signs for these two patients. 1. Review of Patient #1’s medical record revealed an admission date of 08/30/24, with diagnoses to include diabetes mellitus type I, cerebrovascular accident (CVA), chronic kidney disease (CKD) and hypertension. Review of the plan of care/physician’s orders dated 08/30/24 to 10/28/24 revealed orders for skilled nursing twice daily for 9 weeks. The nurse was to complete vital signs, check the patients blood glucose levels and administer medication to include insulin. Review of the skilled nursing notes on 12/05/24 at 4:00 PM revealed on 10/15/24 for the morning and evening visit the nurse, Staff C documented the patient was sleep and he did not assess the patient related to the patient previously refusing not to be awakened on dialysis days. Review of the same skilled nursing notes on 12/10/24 in the agency electronic medical record revealed the form now had vital signs added. During an interview on 12/09/24 at 10:59 AM, Staff C stated on the morning of 10/15/24 he visited Patient #1 and found him on the floor by the couch. He stated the patient liked to sleep on the floor sometimes. He stated he looked at him and he was breathing “fine”, and everything was “ok”. He stated he did not do vitals or obtain the patient’s blood sugar. Staff C stated later that day for the evening visit the patient was asleep and again he did not wake him, check his blood sugar or assess the patient. During an interview on 12/10/24 at 5:00 PM, the Director of Nursing (DON) stated Patient #1 was very noncompliant. She stated the nurse, Staff C, went into the documentation for 10/15/24 over the weekend (12/06/24-12/08/24) and added vitals that weren’t there upon this surveyors arrival and initial medical record review on 12/05/24. She stated Staff C said he made a mistake and put vitals in for the morning of 10/15/24 but remembered he needed to move then to the night visit. The DON verified Staff C stated during the phone interview that he just looked at the patient and saw that he was breathing, set up the medications and left on 10/15/24. Review of the agency policy titled “Skilled Professional Services” revealed patients receiving skilled professional services will receive appropriate assessments, reassessments, care planning, established outcomes and care per physician orders. Skilled professionals must assume responsibility for providing services ordered in the plan of care, preparing clinical notes and communication with all physicians in the plan of care and other health car practitioners related to the plan of care.”

“Contact info for primary care practitioner CFR(s): 484.110(a)(5) Contact information for the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA; and This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the contact information for the patient’s physician was listed in the medical record. This affected one (Patient #1) of three patients reviewed. The census was 25. Findings include: Review of Patient #1’s medical record revealed an admission date of 08/30/24, with diagnoses to include diabetes mellitus type I, cerebrovascular accident (CVA), major depressive disorder, seizures, chronic kidney disease (CKD), left side hemiplegia and hypertension. The patient received outpatient dialysis on Tuesdays, Thursdays and Saturdays. Review of the plan of care/physician’s orders dated 08/30/24 to 10/28/24 revealed orders for skilled nursing twice daily for 9 weeks, and home health aide services of 54 hours per week for nine weeks. On 12/11/24 two attempts were made to contact Patient #1’s Primary Care Physician (PCP) as listed on the patients 485 plan of care/physician’s orders dated 08/30/24 to 10/28/24. However, the number was out of service. During an interview on 12/11/24 at 12:20 PM, the Director of Nursing (DON) stated Patient #1’s physician had retired and she had set up an appointment with a new primary care physician on 09/18/24 however the patient refused to go to the appointment. The DON verified Patient #1 had no PCP from admission on 08/30/24 through his transfer to the hospital on 10/16/24.”